I'm new here but like what I see. I've spent a couple of hours reading articles and the forum since I'm home sick today, found out about the site from Jamie Hale the Wiz. haha

I was wondering if any of you have had experience with athletic pubalgia (incorrectly called sports hernia) ? I'm in the middle of conservative treatment/PT and I'm not convinced my Physical Therapist is right on. He says the main structural issue that caused the wear and tear in my groin/lower ab, eventually causing the tear (which is essentially what athletic pubalgia is) is from lack of TVA activation in stabilizing my pubic bone. I'm concerned because I've talked to no one that the conservative treatment has worked on, and everyone says they eventually get surgery which I obviously don't want.

I'm 29, 6'2, 200 played small college hoops. Never had any real injury's except for a couple ankle sprains, but I gotta a mean anterior pelvic tilt. I hurt myself playing flag football, but the injury is a gradual one that I did sprinting, playing flag football, etc. Love to train and was finally getting close to my goal of double BW squat before I hurt myself! Now I haven't trained in 3 weeks! No surfing, basketball, football, weights, nothing!!

Sorry for the long post I'm eager to learn about this condition as much as I am eager to heal from my injury. Have learned a lot about it but want to get more input from others. Anyone?

I'm no expert on the subject but these are my initial thoughts. You said you have anterior pelvic tilt. From the research I have done I think that may be one of the big reasons for this. APT is a compensation for an improperly functioning Multifidus (deep muscles along the spine). The multifidus and the tva work together to brace the low back and the pubic bone before movement of the arms and legs. With the multifidus not functioning correctly it is might be possible that you have inhibited the tva's function. What's interesting is that a compensation for a dysfunctional tva is POSTERIOR tilt. So there are two dysfunctional muscles which, as far as I can see, have an antagonist and protagonist relationship. You compensate for the low back compensates in one way but you compensate for the tva in another. I can see how the groin/lower ab could caught in a tug of war.

Again, I'm not expert at this and I'm certainly not a physiotherapist or a doctor. This is just some food for thought that I came up with. I would recommend getting that APT under lockdown whenever you're healthy enough to do so. That can cause some pretty big problems, especially with a 2X BW squat.

The strength trainee says "Why sacrifice intensity when I can sacrifice volume"
The bodybuilder says "Why sacrifice intensity when I can sacrifice form"

"We are not sport, when there is a sport issue, we are not so good. The boxer is much better than us at boxing. But he will have to protect his balls if he wants to punch us."

But it is about actual hernias and not pubalgia. Here is the section on sports hernia:

The term “sports hernia” is confusing, even to physicians, because by definition the patient doesn't actually have a hernia. It is discussed under the general topic of hernia because they occur in the groin, and when operation is required the procedure is very similar to a standard hernia repair. But the cause of the hernia is not a hole with a neck and a sac, but rather just weakened or stretched tendons or muscles in the groin area, which leads to pain that interferes with function. The diagnosis is essentially one of exclusion when a patient presents with groin pain and no obvious cause by physical examination or x-ray studies. There is considerable interest in sports hernias because they commonly occur in high profile athletes whose occupations are significantly impacted by the condition.[7]

That's not too much to go on so I'll add to it what I can. Which is to say..there is not too much to add. We have, groin pain but no 'hernia' and a diagnoses of exclusion. The fact is that pubalgia or "sports hernia" is not that well defined and it is likely a whole host of disfunctions and the best definition I have found is:

AP (athletic pubalgia) is a set of pelvic injuries involving the abdominal and pelvic musculature outside the ball-and-socket hip joint and on both sides of the pubic symphysis".

Pretty darn vague and covers a lot of territory. It isn't really a diagnosis but a "category". And actual groin injuries or hip injuries can mimick the same kinds of symptoms and pain.

As far as the therapist goes, there is very little word in the physical therapy world about it and how could there be? It's hardly defined so you have people going to therapist having been diagnosed "by exclusion" and there is not really much established criteria for dealing with it.

TVA is a really popular buzz topic right now and I would wonder if your pt is also a CHEK disciple…blame everything on TVA disfunction form abdominal wall or pelvic floor laxity to low back stability. Or it could be that your therapist figures that core stability is the issue and TVA is the "big news" in core stability for a lot of people.

Sounds like you already have a handle on that judging by what you said so forgive me if I'm going over familiar ground. The question is whether you can expect to get past it with conservative treatment or whether you have to get an undesirable surgery.

While I have has goin pan and gotten past it I've never had a doctor say "sports hernia" to me so I can speak personally on that. However, based on my limited medical knowledge, if you NEED surgery for this kind of thing it is best to get is sooner rather than later because the outcome will tend to be much better and return to full function (or nearly full) is much more assured. So the the hope is that there is a way to find out just how severe things are so that the need for surgery can be assesed. I don't know how much medical advice you've had so far.

There is disagreement as to the usefullness of MRI and/or ultra-sound but I think there is a good indication that those things can help really pinpoint the damage so if you can get some advice on that and maybe get some imaging that may help. So you can decide if it would be best not to engage in wishful thinking and get surgery if you really need it.

Otherwise, training for static and dynamic core stability, like Joe said, in going to be where it is at. It would be great if you could find an actual sports physiotherapist who just MIGHT have more experience with dealing with sports injuries.

And anyway, while were at it where DID you get this diagnoses? If this is about anterior pelvic tilt then that is fairly straighforward, as these things go, to deal with. TVA is a PART of that but it ain't the bread and butter.

There is so much good info here and wish I would have found it sooner!

As far as my APT is is pretty significant. I stretch my hip flexors frequently but should have done a better job working on core stabilization to combat it as well (planks and variations). It's so bad my buddies will make fun of me when I squat because my first reaction to something heavy on my back is to get this hyper-arch going that does look pretty funny I guess. It just felt natural to me. What's interesting is that after I would squat and then move to my uni-lateral movement my entire lower ab region would fee tender, making a lunge variation feel strange. It was a weird feeling which was a probably an early indicator.

Eric what did you groin injury consist of because you are right this a a very gray area injury hard to pin down? My PT assessed me with a number of tests and concluded athletic pubalgia but I was 99% sure before walking into his office this was my plight. He did strike my as a CHEK disciple but is a great rep in town. Many pro athletes including several NHL guys who deal frequently with this condition.

As far as the chronology of the injury, it started with sore groin only on my left side which I didn't consider a big deal but is usually how this injury begins. Then one morning following a sprint workout the day before getting out of bed was tough as I felt I got punched in the lower ab on the left side. Wasn't excruciating pain but uncomfortable. After a couple of days this went away and I went with some guys to play flag football and test 40 times for fun. We ran a lot and tested 40's and other tests explosive in nature and the next day upon waking up I felt jacked up in that lower ab/groin region and was pretty sure something was wrong but with 4 days of rest it subsided again. Played in my flag football game and did fine. Felt bad the next day but it went away in another 4 days or so so I played in our next weekly game and that is when it hit the fan. Strained it badly during the game when trying to explode and it was very painful. Couldn't walk normally for two days, saw the PT and he confirmed my condition. That was almost 3 weeks ago. Now I feel a lot better but wouldn't dare do anything explosive in nature. PT says 3 more weeks of treatment and I can slowly work my way back into the movements I love and miss so much. I appreciatte the static core suggestion I will work more of that in.

This might sound overly simply but if I had to guess I would say one of the main culprits is my lower abs were/are weak and did/do not stablize my pubic bone well enough. The is symptomatic of APT cases too if I'm not mistaken. It's also noteworthy that this was my most productive (not productive if you get hurt but you know what I mean) year of training in terms of adding weight to the bar. Perhaps many compensatory habits were picked up in the process of gettting a bigger squat and dead.

Sorry for the lengthy post. Why has no one recommended a supplement yet? haha

For the APT. A cause of it could be the hip flexors but you're right it could be weak lower abdominals (rectus abdominis). That was the cause of mine. Look into an exercise called 'dead bugs' and give them a shot when you are healthy enough. You may have gotten that tender feeling because your core is trying to brace itself (to support the barbell loading) but you've got a 'hyper arch' so you could be overworking a weak muscle that is already overworked.

APT is really counter active to any sort of heavy lifting. Anytime you're hanging onto a barbell, you've got one on your shoulder or even overhead you need to brace that lower back. Its in the direct load path down to your feet. Even military pressing can be affected by APT.

You may have some compensations playing a role. Start with the APT and some things will iron themselves out I bet.

NOXplod.

The strength trainee says "Why sacrifice intensity when I can sacrifice volume"
The bodybuilder says "Why sacrifice intensity when I can sacrifice form"

"We are not sport, when there is a sport issue, we are not so good. The boxer is much better than us at boxing. But he will have to protect his balls if he wants to punch us."

Thanks for the input. I'll start implementing dead bugs and more plank variations for my lower abs. I can do all of those without any pain. Any other exercises you would suggest? You make a good point, if I just focus on the APT and everything I can do about that especially the lower abs I think I'll be fine in time. As of lately all have been doing rehab wise is isometrics for the adductors (which get stronger daily) and TVA stuff which my PT advised me to do. The TVA stuff seems kinda lame but I do it anyway. I'll implement more lower ab stuff moving forward. Mike Boyle is big on the slideboard for rehabbing and preventing athletic pubalgia so maybe I'll work that in a couple of times a week. To get down to the bare bones it seems like if you (a) have strong enough adductors (especially in proportion to other leg muscles) and (b) strong enough lower ab and (which might be my main problem) (c) symmetrical range of motion in groin and hip flexors (my hip flexors being an issue as well) then you are less likely to end up with this injury. This might be too simple but these are just some observations. Thoughts?

I'll get more in-depth and respond to all the earlier stuff as well later but the dead bug track was developed for TVA dysfunction in the first place. It's a pretty typical intervention for that and is designed to get the TVA firing during limb movement. I got some stuff on that I can put up as well. It's definitely a good idea.

If you need any specific videos of any of the exercises, feel free to ask. I am sure I have taken atleast one video per exercise in the past but if not, I can always take a new one.

Mark Twain:
"Twenty years from now you will be more disappointed by the things that you didn't do than by the ones you did do. So throw off the bowlines. Sail away from the safe harbor. Catch the trade winds in your sails. Explore. Dream. Discover."
"If you tell the truth, you don't have to remember anything."
"Never put off until tomorrow what you can do the day after tomorrow."

Eric what did you groin injury consist of because you are right this a a very gray area injury hard to pin down?

Well actually I've had two major "groin" injuries.

I had a chronic hip flexor strain that was due to my own imbalances and "progressing" too quickly. Very long story and APT was a part of it. So that is the hip flexor and not the 'groin' per se but as you probably know the pain referrs basically to the groin area sometimes.

The second I'm embarassed to say was due to my trying to recapture the glory days when I could do a full side split. I baically stretched the hip adductors too aggressively and got a pretty severe strain which put me off training for quite a while. This is why I get very aggravated with people who think you can't hurt yourself with static stretching becasue the stretch reflex 'turns' off and all of that jazz…I basically say if you think you can't hurt yourself with static stretching then you must not have tried hard enough!

It's also noteworthy that this was my most productive (not productive if you get hurt but you know what I mean) year of training in terms of adding weight to the bar.

Yep. That's not only noteworthy but it's something that I've noticed happens again and again. This is my whole war with the "fastest possible progression" crowd and those who think that the very act of "progressing" by adding weight to the bar means that every thing will just work itself out. Prime time to get injured is right after a big PR that you achieved by things like volume loading and quantity while forgetting about quality.

Anyway, J, I am preparing a whole article on the dead bug track and it's associated assesments and work ups….very simple and step by step to follow. Please be patient with me and I'll get that up ASAP. Lots of info and work going into it.

I have really studied this condition a lot over the last two weeks and I think I've developed a lot of clarity on it and specifically how I developed it. It's actually quite simple.

I started a program about 8 months ago to get my vertical jump up to 30 inches (it was 25 inches to start). My absolute strength has always been my limiting factor as I played years of basketball (since 6 years old, life long passion, played small college, and now I coach) so my reactive ability is very good but again my absolute strength not great. So…my focus was to stay moderately lean and jack up my squat! This was a "success" going from 275lbs or so all the way to 350lbs. I was so stoked to hit 350, totallly uncharted waters. This is where it gets really interesting pertaining to my condition.

The whole time I monitored form and what not and made sure reps where solid but all the while totally ingnoring the fact that my APT was getting more drastic, continuing to take me abs out of the equation and continuing to neglect them with additional training. MOST OF MY STUDYING ON THIS POINTS TO THE MAIN CAUSE BEING INADEQUATE CORE STRENGTH PROPORTIONATE TO LEG POWER! That kind of sums it all up.

I started to sprint more and play some intense flag football, with my new found strength…and speed. Definitely enjoyed some speed improvements. But…now I'm on the shelf. Make sense?

I'm no expert but this train of thought makes a lot sense to me? I'm going to continue to rest and adress the APT, especially with core work. It's so stupid when you think about the crowd that screams you don't need additional core work if you do the good lifts because you can just continue to re-emphasize bad postural habits and strong areas get stronger and weak areas get exposed.

Yeah, you summed it up. It's the jigging and jagging that probably was the factor in the play. Sudden stops and changes of direction where you have to redistribute your body weight. And with huge forces involved.

It's so stupid when you think about the crowd that screams you don't need additional core work if you do the good lifts because you can just continue to re-emphasize bad postural habits and strong areas get stronger and weak areas get exposed.

Yea verily

Once this starts getting better maybe you'd like to start another thread outlining your strength training habits up till now and we can give suggestions for the future.

Looking forward to that doc Eric. Speaking of the dead bug maybe you'll get into this later but I've seen some prescribe a posterior tilt and lower back sucked into the floor with no space (Robertson, Cressey) but have also seen a more nuetral spine more recently being advocated to emphasize TVA involvment. In a posterior tilt it would be pretty much all RA and no TVA if I'm not mistaken. I'm a little torn/confused because I think my PT is very intelligent but continues to beat the TVA drum in regards to my rehab but Mcgill has made a lot of sense out of why you can't isolate the TVA and shouldn't even try. Hmmmm. I've learned so much in hours of study on this this injury and I'm almost back to square one in regards to diagnosing the main culprit. For example my APT is significant but my abs test well and the planks and strength and endurance tests. Thoughts fellas? I thought it might be as easy as inadequate core strength to deal with leg strength and power in sprinting and direction changing at high velocities but like I said I'm not sure the core is that weak after all. ????

I was just thinking this so take it at face value. BUT when you do any sort of abdominal strength test you are EXPECTING to use your abs and you're going to be ready to assume a plank position or what have you. In the case of running, doing quick cuts, sprinting out of blocks, and even squats, if you can't engage your core properly or quickly enough under dynamic movement patterns like that then it doesn't matter how long you can hold a plank.

The strength trainee says "Why sacrifice intensity when I can sacrifice volume"
The bodybuilder says "Why sacrifice intensity when I can sacrifice form"

"We are not sport, when there is a sport issue, we are not so good. The boxer is much better than us at boxing. But he will have to protect his balls if he wants to punch us."

Speaking of the dead bug maybe you'll get into this later but I've seen some prescribe a posterior tilt and lower back sucked into the floor with no space (Robertson, Cressey) but have also seen a more nuetral spine more recently being advocated to emphasize TVA involvement.

Well now you know why this takes me so long! Do I write pages of explanation to try to eliminate all the confusion and in the end simply create more confusion? Or do I say..here's how to do it and here's a brief explanation as to why.

Combining the two things, McGill and the issue of planting the back or just using a neutral I can create all sorts of confusion right now. First of all when McGill talks about the issue of abdominal hollowing what he is trying to do is counter the myth that the transverse abdominus and multifidinus are the "keys" to spinal stability and you can use abdominal hollowing to activate them thus creating a more stable spine during heavy lifting or athletic activities (two COMPLETELY different things, really). He is countering "CHEK" and the "Australians" who preach that stuff. He says (and so do I) you want to use abdominal bracing but abdominal bracing is NOT the same as abdominal hollowing and you need ALL the muscles and you want to INCREASE the distance between the "hoops" of the abdomen not decrease it. So what he means is you don't go around lifting heavy weights or playing football with your gut sucked in. Unless you want to look like a supreme douche like Paul Check weezing your way through a workout (you can't BREATHE properly with you gut sucked in…it inverts your breathing).

Okay so what about "isolating" the TVA (and MF). Yes, many believe some people can preferentially activate it, etc…McGill says he saw no evidence of this. But he doesn't say that abdominal hollowing doesn't contract the TVA because of course it does. The question therefore is can you do that in a way that doesn't use any superficial muscle activity.

For instance, some sources say, during these spinal stabilization tracks, that you must learn to do abdominal hollowing using the TVA, multifidinus and "deep pelvic floor" muscles preferentially and to do that during the dead bug for instance you would place some fingers about an inch medially and inferior to the superior iliac spine and attempt to palpate the TVA and do kegel like contractions to feel it as opposed to using action of the superficial musculature of like the RA and obliques.

As an example, in Conservative Management of Sports Injuries, the author instructs, after getting in the hook lying position and palpating the TVA:

Instruct the athlete to take a deep breath in and then gently let the breath out. Make sure she does not forcefully exhale because this will activate the superficial oblique and rectus abdomonis muscles. At the end of the expiration have the athlete cease breathing and then slowly and gently attempt to draw in the abdomen toward the spine. Once she has successfully accomplished the contraction, have her attempt to resume normal breathing. Often she will lose control of the contraction when she attempts to breathe normally.

Now, the idea is you do it that way and you will preferentially recruit the TVA and the MF. And there is some logic in that except of course it raises all sorts of other questions such as "normal breathing" for an athlete lying on the floor is not the same as normal breathing for an athlete in motion. And McGill would HAVE to have issue with that! He teaches us to develop an "athletic diaphragm" and you do NOT do that with your gut sucked in while relaxing on the floor.

Okay so there is still at least somethign to be said for that but the question is does all of that matter? CAN you isolate it really? I don't know and I DON'T care.

Getting into the MR and EC question and whether the back should be planted that is a sensitive issue and whats more important than the RA and all of that is whether you can do that without pain. They are assuming no active injury. If you do not functional range of motion in the pelvis that allows you to assume that position and do the exercise without pain then you should NOT be doing that.

Like I said before the idea of the dead bug is to train the TVA and all of that. But the reason and Joe brought it up and the reason that MR wrote about it is because it is really good for helping to correct the anterior pelvic tilt. If it were me I would not bothered too much with all the TVA this, RA that, and multifidinis whatever. You say that this week there will be another EMG study showing something and once again proving nothing. What matters to me is do the movements solve the problem. I dont' care if I'm contracting the damn RA or what. It's not like I'm going to be doing dead bugs for any other purpose but corrective..once the "correction" is made I'm not going to be thinking back and wondering about the individual muscles that were used. I'll leave that to guys doing EMG studies or hanging out in seminars debating it.

MR's method of using a flat back and an abdominal hollowing works very well as part of a stategy to correct APT. I think, if I recall the idea was the hollow for the TVA and MF and the flat back for the RA or something like that but I don't remember because I gloss over that stuff. Not out of disrespect for Mike but just because, in my experience anytime someone talks about individual muscles in things like this it leads me to ten million other questions that are really not all that important at the end of the day. DETAILS are the fuel of analysis paralysis.

But regardless tilting the pelvis posteriorly while in the hook lying position is not exactly the biggest feat in the world. But as you straighten the legs and you have tight hip flexors is becomes more and more difficult. The posterior pelvic tilt in a supine postion is both a way of grading the abdominals and a way of exercising them towards correcting anterior pelvic tilt. And "sucking in the gut" is a part of that correction. Remember it's not just the RA it's also obliques that are very important (btw what about tight hip flexors?).

The dead bug track, as it was conceived was just the abdominal hollowing, a neutral spine, and extremity movements. Combining that with posterior pelvic tilt makes for a very good way to correct APT assuming that the APT is part of a postural problem. However, I DON'T think it is necessary to have the back on the floor. Using a rolled up towel underneath the spine is fine if needed. It's the action of doing it that matters.

Are you confused by all of this? Because I've confused myself.

For example my APT is significant but my abs test well and the planks and strength and endurance tests.

I really think Joe is right on with his answer to that. To add to that it is part of the reason why McGill harps on breathing patterns, I think. You know many people can't properly engage their core while breathing heavy. When it comes to lifting (and McGill brings this up as well) it's totally different in terms of breathing. But as Joe said, getting down in a prone position and doing a nice leisurely plank is not really a good test for an actual dynamic athletic environment. It's much better for say, assessing whether you are good to go for deadlfits and things of that nature.

You are assuming also, with the abs, that anterior pelvic tilt is always accompanied by weak and elongated abdominals.

I don't think any of us here should really be trying to "diagnose" you though. All we can do is try to do the right thing and not make things worse. I am actually a little surprised by the idea of a physicaly therapists "diagnosing" a sports hernia because as we have discussed quite thouroughly there is no confidence in even a medical diagnosis of that involving imaging. I've heard lot's of coaches and what not throw around the term sports hernia whenever they hear groin pain and I don't think they have any business doing so.